Access to comprehensive services for HIV and non-communicable diseases in sub-Saharan Africa
Authors: Sayoki G Mfinanga
Journal: The Lancet Global Health (2023)

In sub-Saharan Africa, the emerging burden of non-communicable diseases alongside a continuing high burden of communicable diseases is a major public concern.1Naghavi M Abajobir AA Abbafati C et al.Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (3240) Google Scholar, 2Zimmermann M Bunn C Namadingo H Gray CM Lwanda J Experiences of type 2 diabetes in sub-Saharan Africa: a scoping review.Glob Health Res Policy. 2018; 3: 25Crossref Scopus (26) Google Scholar, 3Bosu WK Reilly ST Aheto JMK Zucchelli E Hypertension in older adults in Africa: a systematic review and meta-analysis.PLoS One. 2019; 14e0214934Crossref PubMed Scopus (67) Google Scholar An estimated 2 million people in sub-Saharan Africa have complications from hypertension or type 2 diabetes,1Naghavi M Abajobir AA Abbafati C et al.Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (3240) Google Scholar, 2Zimmermann M Bunn C Namadingo H Gray CM Lwanda J Experiences of type 2 diabetes in sub-Saharan Africa: a scoping review.Glob Health Res Policy. 2018; 3: 25Crossref Scopus (26) Google Scholar, 3Bosu WK Reilly ST Aheto JMK Zucchelli E Hypertension in older adults in Africa: a systematic review and meta-analysis.PLoS One. 2019; 14e0214934Crossref PubMed Scopus (67) Google Scholar and this number is increasing. With few resources and weak health-care systems in sub-Saharan Africa, ensuring universal access to non-communicable disease services such as screening, diagnosis, and low-cost treatment is extremely challenging. In the past 10 years, evidence has emerged showing some cost-effective interventions that could increase access to health care, such as integrated services for these chronic conditions.4Shiri T Birungi J Garrib AV et al.Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings—an empirical socio-economic cohort study in Tanzania and Uganda.BMC Med. 2021; 19: 230Crossref Scopus (9) Google Scholar, 5Birungi J Kivuyo S Garrib A et al.Integrating health services for HIV infection, diabetes and hypertension in sub-Saharan Africa: a cohort study.BMJ Open. 2021; 11e053412Crossref Scopus (11) Google Scholar Public health authorities should prioritise research and implement service models for the best care of chronic conditions such as HIV, diabetes, and hypertension in all settings with few resources. However, tools for assessing the access and quality of services, such as met and unmet health needs, are uncommon in most low-income countries, which should be addressed. In The Lancet Global Health, Singh and colleagues6Singh U Olivier S Cuadros D et al.The met and unmet health needs for HIV, hypertension, and diabetes in rural KwaZulu-Natal, South Africa: analysis of a cross-sectional multimorbidity survey.Lancet Glob Health. 2023; 11: e1372-e1382Google Scholar report findings from data collected for the Vukuzazi study, a cross-sectional multimorbidity survey conducted in the uMkhanyakude district of KwaZulu-Natal, South Africa. The authors calculated the health needs of people with HIV, diabetes, hypertension, or any combination of these conditions. The study was conducted within the demographic and health surveillance area of the Africa Health Research Institute. Singh and colleagues defined the five health states as not having the condition, diagnosed and receiving optimal treatment, diagnosed and receiving suboptimal treatment, diagnosed but not engaged in care, and undiagnosed but had a positive screening test in the Vukuzazi study. The authors defined the lowest needs score as zero, representing people with no disease and therefore no health system needs, and the highest needs score as four, representing people with the highest unmet health needs including no diagnosis, care engagement, optimised treatment, or supply of medicine. The authors reported that 9898 (54·9%) of the 18 041 individuals who enrolled in the Vukuzazi study had at least one of the three measured health conditions. 1617 (93·1%) of 1737 people who screened positive for diabetes, 2681 (58·2%) of 4603 people who screened positive for hypertension, and 1321 (21·7%) of 6096 people who screened positive for HIV had unmet health needs. In other words, the health needs of people with HIV were generally well met, whereas the health needs of people with non-communicable diseases were poorly met by existing health systems. I commend the authors for developing this tool and quantifying the health needs of people living with chronic conditions in a setting with few resources. Their study provides further evidence of the unmet needs of people living with non-communicable diseases.7Berry KM Parker WA Mchiza ZJ et al.Quantifying unmet need for hypertension care in South Africa through a care cascade: evidence from the SANHANES, 2011–2012.BMJ Glob Health. 2017; 2e000348Crossref Scopus (79) Google Scholar, 8Stokes A Berry KM Mchiza Z et al.Prevalence and unmet need for diabetes care across the care continuum in a national sample of South African adults: Evidence from the SANHANES-1, 2011–2012.PLoS One. 2017; 12e0184264Crossref Scopus (62) Google Scholar The visual geospatial data analysis of the health-needs distribution of each condition will help with planning and prioritising strategies and resources for populations who require services the most. This research should be repeated in other settings, including those where demographic and health surveillance are not currently being done, as the amount of unmet health needs (eg, in diagnosis) could be much higher, potentially due to reduced knowledge of the disease, reduced access to health services, or other reasons. There are now plans to integrate services for diabetes and hypertension into HIV programmes in some settings in Africa. This integration is crucial as, otherwise, the rapid increase in diabetes and hypertension incidence could undo some of the improvements in patient survival that were painstakingly achieved by HIV programmes. However, in sub-Saharan Africa, the number of people living with diabetes or hypertension is now at least four times higher than the number of people living with HIV,2Zimmermann M Bunn C Namadingo H Gray CM Lwanda J Experiences of type 2 diabetes in sub-Saharan Africa: a scoping review.Glob Health Res Policy. 2018; 3: 25Crossref Scopus (26) Google Scholar, 3Bosu WK Reilly ST Aheto JMK Zucchelli E Hypertension in older adults in Africa: a systematic review and meta-analysis.PLoS One. 2019; 14e0214934Crossref PubMed Scopus (67) Google Scholar, 9WHOHIV/AIDS.https://www.afro.who.int/health-topics/hivaidsDate: 2023Date accessed: May 25, 2023Google Scholar so integration with HIV clinics will mean very large numbers of people living with non-communicable diseases will continue to have unmet health needs. African health services should now consider fully integrated chronic care clinics, whereby people with either HIV, diabetes, hypertension, or any combination of these conditions can receive comprehensive and continuous care.10WHOWorld Health Organization guidance on integrating the prevention and control of noncommunicable diseases in HIV/AIDS, tuberculosis, and sexual and reproductive health programmes.https://www.who.int/news/item/05-04-2023-world-health-organization-guidance-on-integrating-the-prevention-and-control-of-noncommunicable-diseases-in-hiv-aids-tuberculosis-and-sexual-and-reproductive-health-programmesDate: 2023Date accessed: May 25, 2023Google Scholar There is an urgent need for a call to action by global, national, and regional health organisations, development partners, and research institutions to address the comorbidity and multimorbidity of HIV and non-communicable diseases in sub-Saharan Africa. The focus should include, but not be limited to, enhancing public and professional awareness of disease burden, promoting effective interventions, advocating for policy change, strengthening health-care systems to promote integrated care models that consider the holistic needs of individuals with comorbidities and multimorbidity, and fostering multidisciplinary collaborative research to generate evidence-based interventions and empower communities and patients to actively participate in their care. By doing so, sub-Saharan African countries can proactively tackle these challenges and promote better health outcomes, improved quality of life, and sustainable health-care systems. I declare no competing interests. The met and unmet health needs for HIV, hypertension, and diabetes in rural KwaZulu-Natal, South Africa: analysis of a cross-sectional multimorbidity surveyAlthough people living with HIV predominantly have a well controlled condition, there is a high burden of unmet health needs for people living with hypertension and diabetes. In South Africa, adapting current, widely available HIV care services to integrate non-communicable disease care is of high priority. Full-Text PDF Open Access